II. Epidemiology

  1. Incidence: 1 to 1.5 per 100,000
  2. Cerebroarterial Dissections (Carotid Artery and Vertebral Artery) are uncommon (<2%) causes of Ischemic CVA
  3. Age
    1. Younger patients account for up to 25% of Vertebral Dissection related Ischemic CVA
    2. Peak Incidence age 50-60 years
  4. Gender
    1. Women are affected at a younger age than men

III. Pathophysiology

  1. Vertebral Artery media tear (middle muscular, arterial layer) allowing blood intrusion into arterial wall
    1. Resulting intramural thrombus occludes vessel with risk of CVA

IV. Causes

  1. See Vertebral Artery Injury in Blunt Neck Trauma
  2. Genetic Predisposition, Typically Connective Tissue Disorder (spontaneous dissection)
    1. Ehlers-Danlos Syndrome Type IV
    2. Marfan's Syndrome
    3. Autosomal Dominant Polycystic Kidney Disease
    4. Osteogenesis Imperfecta Type 1
  3. Hypertension or rotation of the neck (esp. if sudden)
    1. Yoga
    2. Painting ceiling
    3. Coughing, Sneezing or Vomiting
    4. Procedural Sedation
  4. Chiropractic Manipulation (1 in 20,000 Spinal Manipulations)
    1. Hufnagel (1999) Neurol 246: 683-88 [PubMed]
  5. Respiratory infection
    1. Autumn peak in dissection Incidence also may suggest infectious contributing factors
  6. Other possible risk factors
    1. Coronary Artery Disease Risk Factors
    2. Migraine Headache

V. Types

  1. Ischemic Vertebral Artery Dissection
    1. Resulting cerebral ischemia or infarction
    2. Many dissections heal spontaneously and occluded vessels may be compensated by opposite Vertebral Artery
  2. Rupture of Intradural Vertebral Artery dissecting aneurysm (hemorrhagic)
    1. Subarachnoid Hemorrhage
    2. Unstable with high risk of recurrent bleeding (70% of cases, most within first week, and mortality 47%)

VI. Findings

  1. Extracranial Vertebral Artery Dissection (primarily at C1-2)
    1. Occipitocervical region severe pain
    2. Vertebrobasilar Ischemia or Infarction Symptom
      1. Dizziness
      2. Vertigo
      3. Diplopia
      4. Ataxia
      5. Dysarthria
    3. Vertebrobasilar Infarction
      1. Cerebellar infarction
      2. Wallenberg Syndrome
      3. Spinal Cord Infarction
  2. Intracranial Vertebral Artery Dissection
    1. Subarachnoid Hemorrhage in 50% of cases
    2. High rebleeding rate, poor prognosis, high mortality
    3. Responsible for up to 10% of non-Traumatic Subarachnoid Hemorrhage
    4. May be minor in some cases

VII. Imaging

  1. MR Angiogram
    1. Has largely replaced CT Angiogram as gold standard, with similar efficacy
  2. CT Angiogram
    1. As with MRA, CT angiogram has high Test Sensitivity

VIII. Prognosis

  1. Extracranial Vertebral Artery Dissection
    1. No deficit 50%
    2. Mild deficit 21%
    3. Moderate to severe deficit 25%
    4. Mortality 4%
  2. Intracranial Vertebral Artery Dissection
    1. Associated with severe neurologic deficits

IX. Management

  1. Anticoagulation (unless contraindicated, e.g. Hemorrhage)
    1. Intravenous Heparin, then
    2. Oral Anticoagulant
  2. Surgical interventions
    1. Endovascular procedures
    2. Vascular ot Neurosurgery

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Related Studies

Ontology: Vertebral Artery Dissection (C0338586)

Definition (MSH) Splitting of the vessel wall in the VERTEBRAL ARTERY. Interstitial hemorrhage into the media of the vessel wall can lead to occlusion of the vertebral artery, aneurysm formation, or THROMBOEMBOLISM. Vertebral artery dissection is often associated with TRAUMA and injuries to the head-neck region but can occur spontaneously.
Concepts Disease or Syndrome (T047)
MSH D020217
ICD9 443.24
ICD10 I77.74
SnomedCT 230730001
Swedish Vertebralisdissektion
Czech arteria vertebralis - disekce, arteria vertebralis - disekující aneurysma, Disekce vertebrální arterie
Finnish Nikamavaltimon dissekoituminen
Russian POZVONOCHNOI ARTERII DISSEKTSIIA, ANEVRIZMA RASSLAIVAIUSHCHAIA POZVONOCHNOI ARTERII, POZVONOCHNOI ARTERII RASSLAIVAIUSHCHAIA ANEVRIZMA, POZVONOCHNOI ARTERII RASSLOENIE, АНЕВРИЗМА РАССЛАИВАЮЩАЯ ПОЗВОНОЧНОЙ АРТЕРИИ, ПОЗВОНОЧНОЙ АРТЕРИИ ДИССЕКЦИЯ, ПОЗВОНОЧНОЙ АРТЕРИИ РАССЛАИВАЮЩАЯ АНЕВРИЗМА, ПОЗВОНОЧНОЙ АРТЕРИИ РАССЛОЕНИЕ
English dissection of vertebral artery (diagnosis), dissection of vertebral artery, Dissecting Vertebral Artery Aneurysm, Artery Dissection, Vertebral, Artery Dissections, Vertebral, Dissection, Vertebral Artery, Dissections, Vertebral Artery, Vertebral Artery Dissection, Vertebral Artery Dissections, Dissect vertebral artery, Dissection of vertebral artery, Vertebral Artery Dissection [Disease/Finding], vertebral dissection artery, vertebral artery dissection, Vertebral artery dissection, Vertebral artery dissection (disorder)
French Dissection artérielle vertébrale, Dissection de l'artère vertébrale, Anévrisme disséquant de l'artère vertébrale, Anévrysme disséquant de l'artère vertébrale, Dissection d'artère vertébrale, Dissection vertébrale
Polish Rozwarstwienie tętnicy kręgowej
Japanese 解離-椎骨動脈, 椎骨動脈解離, ツイコツドウミャクカイリ, 動脈解離-椎骨動脈, 椎骨動脈瘤解離, 解離性椎骨動脈瘤
Spanish Disección de arteria vertebral, disección de arteria vertebral (trastorno), disección de arteria vertebral, Aneurisma Disecante de la Arteria Vertebral, Disección de la Arteria Vertebral
Portuguese Dissecção de artéria vertebral, Dissecção da Artéria Vertebral, Aneurisma Dissecante da Artéria Vertebral, Dissecação da Artéria Vertebral
Dutch halsslagaderdissectie, Dissectie van arteria-vertebralisaneurysma, Dissectie, vertebralis-, Vertebralisdissectie
German Dissektion der Arteria vertebralis, A. vertebralis-Dissektion, Dissezierendes Aneurysma der A. vertebralis
Hungarian Arteria vertebralis dissectio
Norwegian Disseksjon av vertebralisarterieaneurisme, Vertebralisarteriedisseksjon, Disseksjon av vertebralisarterien
Italian Dissezione dell'arteria vertebrale